An Open Letter to EveryDayHealth.com

The following letter was submitted by a physician in the Sermo community.  We thought it was important enough to share and spark conversation.  What about the line between physicians and medical journalism?  What about the information that gets conveyed to patients and how they might interpret that?  We’d love to know your thoughts in the comment below this letter.

Good morning:

I’d like to give you some useful information regarding the column you wrote about anesthesia, especially in regards to awareness under anesthesia. I’ve been an anesthesiologist for 17 years, was chief of obstetric anesthesia and chair of residency education for the largest residency program in the US. Since 2004, I’ve been in private practice. I take patient safety – especially the issue of awareness under anesthesia – extremely seriously. In 1981, as a student at Yale and the victim of a violent crime, I underwent emergency surgery and experienced being paralyzed and awake while they operated on my abdomen. The next day when the surgeon came by to visit, I quoted his entire conversation with the resident and medical student. He nearly collapsed, turning pale green – and then had me moved to a private room with only he and the head nurse following me for the rest of my stay.

The reasons for people being aware are as follows:

1) Blood loss. If your blood is leaving your body, there goes your anesthetic. Blood carries anesthesia to your brain. If your blood is leaving your body, you are at risk of awareness. Consequently, heart bypass patients are at the most risk (not necessarily blissfully unaware) and may be aware even though we know and try to prevent it. Other large blood loss surgeries include major transplants (liver, heart, lung, multivisceral), stat C-sections for bleeding, traumas with bleeding, major vascular surgery.

2) People who use drugs (whether prescription or illicit) or alcohol who don’t divulge their use patterns. That one you had right. The brain has receptors where these substances work. If the brain becomes accustomed to a certain level of receptor use, then we need to give more.

3) Women of child-bearing age are at greater risk than any other group of individuals. The reason is unknown, but a good guess is higher levels of those hormones responsible for being of childbearing age.

As for being unresponsive to pain – well that is completely erroneous. The spinal cord carries the pain signals to the brain and the body reacts with all the same hormonal responses as if it were awake. But because general anesthesia is a chemically induced coma, a person isn’t likely to recall what caused those responses. The only way to prevent the body from feeling/brain reacting is to stop the pain signal from making it to the brain. Spinal anesthesia, peripheral nerve blocks, and local placed in the incision BEFORE cutting, are the only way to block the pain signals.

It’s true that insurance in certain instances may not cover anesthesia. Because the federal government (CMS) decided what procedures require anesthesia services and under what circumstances, the private insurance companies followed suit. Procedures like colonoscopy and EGD are typically not covered unless the patient has met very certain criteria. Patients can pay out of pocket – but it is better to negotiate the price up front, which is totally legal.

Sore throat can happen even without an endotracheal tube (breathing tube) being placed. Laryngeal Mask Airways (LMA) rest back where the tonsils live – the pressure can give you the sensation of a very sore throat. Likewise, I’ve had patients who only had oxygen during sedation, yet complained of sore throat – because medical oxygen has no humidity coupled with the dry air of the OR environment.

As for cases under sedation, personally I make the patient understand that they may recall events in the OR. If the patient becomes uncomfortable, we will give more sedation IF the patient isn’t in any danger of having worse problems with deeper sedation. Some patients are just too sick to give much medication – but I make that clear from the outset.

Death rates/incidence is actually a spectrum based on the patient’s health, the type of surgery

Personally, when I catch anyone doing anything other than attending to the patient, I’m very stern about it. There are approximately 44,000 anesthesiologists in the US that are board certified. Thousands of people undergo anesthesia every day. Having been very active in a variety of medical society settings, I can assure you, the vast majority of anesthesiologists are hyper-aware of the issue of patient awareness – and try to avert it from ever happening.

I hope this helps you. The reason I wrote is that while your column may help patients approach the issue, there was some misinformation. No one in anesthesia should be doing anything other than paying attention to the patient. The idiot who was posting on Facebook while taking care of a patient was just that: an idiot. If I caught anyone posting to Facebook while in the OR, I would want that person fired. Period.

Thanks for your time and consideration.

Bio:

Joy Steadman, M.D. is the chief anesthesiologist at DMH Systems in Maryland.  She has been practicing medicine for 20 years.  She is formerly the Vice Chief of Anesthesiology at AAH, and the Director of Obstetric Anesthesia at the University of Miami.